Verification of Benefits

Please complete the Verification of Benefits Request Form found on this webpage. We will speak to your insurance provider to verify which benefits are covered with your health plan.

Policy Holder Information

Please provide the information for the primary policy holder of the insurance plan. In some instances, the policy holder is not the patient, and is typically the person who is financially responsible for the policy's monthly premium.

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Patient Information

If the patient is not the policy holder, please provide the following information. If the patient and the policy holder is the same person, you can leave these fields blank.

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Insurance Information

Please provide the following information located on the front and back of your insurance card.

Visit Information

Please provide information on which healthcare provider you would like to visit, and which healthcare service you would like to receive.

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We will send a copy of your Verification of Benefits form to this email address.

Submitting this form does not guarantee insurance coverage of benefits, and is provided as a free service to you on behalf of Prestige Total Health. You can request a copy of your verification of benefits form by contacting the medical records department of the provider's office. Upon verification, a completed Verification of Benefits form will be submitted to your healthcare provider to help determine the patients financial responsibility.